Ex-post Evaluation

1. Background of the Project

JICA assistance in Tuberculosis control in Nepal dates back in 1960's. Cooperation at the national level however was conceptualised in 1985 following the Nepal visit of Princess Chichibu. Comprehensive assistance at the national level was started in 1987 as Phase I project implemented from 1987 till 1994 with emphasis on capacity strengthening and establishing infrastructures including reorganisation of central office in NTC building. Encouraged by the success of the Phase I project, JICA initiated Phase II assistance to NTP started on 1994 with the aim of strengthening the National TB Programme (NTP) ultimately contributing to the promotion of public health and welfare in the kingdom of Nepal.

2. Project overview

JICA TB Control Project, Phase II emphasised on overall capacity strengthening of National TB Programme. The project rather than focusing on specific aspect of the TB had a broad and comprehensive approach so that all aspects of NTP are strengthened. Input in policy development, emphasising the training, logistic supply, recording and reporting, and supervision/monitoring system were major areas of intervention.

a. Overall goal

The overall goal of the Project was to strengthen the activities of NTP through the primary health care structure and thus contribute to the promotion of public health and welfare in the Kingdom of Nepal

b. Project Purpose

• To improve the organisational and functional aspects of NTP through the PHC structure, emphasising the training, logistic supply, recording and reporting, and supervision/monitoring system.
• To improve the treatment results of tuberculosis cases in the model areas in the Western Region so as to replaceable in other districts

c. Outputs

• Personnel involved in tuberculosis activities are trained
• Institutional network for the timely and appropriate distribution of Anti-tuberculosis drugs is established, and more tuberculosis patients have access to chemotherapy at the peripheral level.
• Epidemiological situation and statistics on tuberculosis patients and activities are monitored more correctly.
• The coverage of NTP is expanded through a standardised method
• Completion rate of tuberculosis treatment is improved in model area of the Western Region
• Smear examination service is implemented and its quality is improved in model areas of the Western Region

Inputs (Japanese side)

Inputs (Nepalese side)

3-1 Summary of Evaluation Results

(1). Impact

Table below indicates that there is a consistent rise in some of the success indicators for TB programme during the Phase II support period. NTP has been successfully expanded merely from 1.7% population coverage (1996) to now 94% (2002). Likewise the expansion is being supported by the increased government budget although that is not adequate to cover the total cost of NTP. TB Control programme in Nepal is considered to be one of the successful programmes by national and international reviewers. However, there is room for improvement particularly in the area of access and financing the drug cost. Currently 22 out of 75 districts still have one DOTS centre, and only 2 districts have more than 10 DOTS Centres. Further, no negative impact related to Phase II was reported or observed during the whole study period.

(2). Sustainability

Institutional
The microscopy centres, DOTS centre and supervision system are being fully managed by government staff. Moreover, the TB function is fully integrated within the Primary Health Care structure; therefore the staffs at the peripheral health units are effectively implementing NTP. Training and supervision systems are being carried out smoothly even after JICA assistance was withdrawn. The training facilities and staff are fully being utilised even after the completion of the project.
The staffs who have received training in Japan have been contributing directly or indirectly to the TB control in Nepal. Moreover, since the training was provided to Ministry of health staff, even they are transferred from NTC; they still remain in position in which they are utilising the skills and knowledge in their day-to-day professional job.
The expansion of NTP continued even after the project was completed. Three years after the completion of JICA project, the expansion has been continued and has reached 94% coverage with more than 293 DOTS Centres. Similarly, microscopy centres have been supplied with JICA procured Microscopes – almost 73% of total TB microscopy laboratory are provided with NTP microscope – who are regularly examining sputum of TB suspects and sending report to NTC. The service delivery part of NTP is decentralised up to sub Health Post and to DOTS centre level, although budget and decision making appears centralised.

3-2 Factors promoting sustainability and Impact:

~on planning~

• TB is considered as a major public health issues in 2^nd Long-term health plan and other government policy documents (10th Plan), therefore is likely to receive priority attention both from government and donors. Political commitment is reflected partly in increased budget from government side every year.
• JICA has been cooperating on the national policy itself, and has not made 'double-track'.

~on implemnentation process~

• Not only central level, JICA also made good relationship with stakeholders in the district and community level.
• JICA introduced simple technology and systems that Nepalese can easily learn and sustain the activity. JICA also put a lot of effort to followup until they take root.

3-3 Factor inhibiting sustainability and impact:

~on planning~

After the recent organizational/policy change in the government, structural position, role and function of RTC in relation to regional directorate and NTC is not clear. As a result, RTC does not seem to be fully utilized as expected, considering its potential.But it was very difficult to predict this situation when planning.

~on implemnentation process~

• Government lacks specific long and short-term plan for ensuring supply of anti TB drugs after 2005 when external assistance for drug comes to an end.

3-4 Conclusions:

The JICA inputs, along with other donors inputs have been instrumental in strengthening the NTP. The TB programme has been repositioned and upgraded with contribution from the JICA assistance. The commitments, space created, and technical and financial assistance to NTP have not only strengthened the overall NTP, but also have opened up the avenues of opportunity for many development partners to play a role in NTP.

The quality TB service is being continued with expansion of programme throughout the country. municipalities, VDCs and private sectors are now collaborating with NTP. Although there is regular increase in national budget for NTP, the drug component is largely dependent on external assistance.

3-5 Recommendations:

Despite decentralisation of the implementation of TB programme, the budget allocation pattern and decision-making indicates centralisation. Peripheral units are required to take many decisions that would promote the sustainability but they have little resources and mandate for this. Therefore decentralisation needs to be promoted, as appropriate.
Injection of technical and financial input at a critical point of evolution of NTP has not only strengthened and expended quality TB control services in the country making it one of the best programme, but also has created opportunity for many development partners to play a role in TB programme. Therefore future assistance should also be aimed at addressing the critical point of policy evolution.
Given the complex nature of health financing in developing countries, the definition, understanding and approaches to financial sustainability needs to be well-discussed and agreed with the government and other partners during the design phase of the project.
Changes in the government policy and its immediate and future implication at particular project intervention are often a crucial aspect that needs to be monitored carefully and make adjustments accordingly.
NTP should more focus on rural areas where there is only one DOTS centre in a district so that NTP can reach almost all the population in Nepal.

3-6 Lesson learned

A national programme implemented through existing structures without creating parallel structure is likely to be absorbed in the system and continued even after the withdrawal of external assistance. JICA Phase II was the case in point here.
The systems developed during Phase II are being used in NTP because the system was developed with the direct involvement of the people who is supposed to be using it. This has promoted a sense of belonging while at the same time the users have owned it.

NTC needs to gradually evolve as a Central Referral Unit while at the same time focusing on policy development, monitoring, resource mobilisation and research activities. Field implementation role should be gradually decentralised further so that peripheral units, including RTC can assume more responsibilities and the coverage and access is improved. NTC may seek donors' assistance in these areas.

3-7 Follow-up

JICA has been executing ' Community Tuberculosis and Lung Health Project' following the two project. Under the CTLHP, JICA has been focusing on the urban DOTS programme and trying to strengthen the NTP more. In addition to that, JICA set the target wider to 'lung health' such as anti-smoking activities and ARI(Acute Respiratory Illness), using the experiences and approaches of decades' TB control projects.